Restricted Driver License Application

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Restricted Driver License Application

Use this form to apply for a temporary restricted driver license if your driving privilege in Washington is currently suspended or revoked. To apply, take this completed application and a $100 nonrefundable application fee to any driver licensing office or mail your application with a check or money order payable to the Department of Licensing to:

Restricted Licensing Department of Licensing PO Box 3907 Seattle, WA 98124-3907

For validation only 106-040-254-0005

Restricted license fee___________ Date received____________ LSR initials___________________ Office no.________________

PRINT OR TYPE Name (Last, First, Middle initial)

Driver license number

State/Jurisdiction

Date of birth

(Area code) Daytime telephone number

Address (Street address or PO Box, City, State, ZIP code)

Gender

M F X

Height

Weight

Eye color

Eligibility/Restrictions ? We will determine what type of temporary restricted license you qualify for based on our evaluation of your driving record. ? Any restricted license issued will only be valid within the state of Washington and cannot be used to operate a commercial

motor vehicle. ? We may also restrict where and when you can drive. ? Your suspension/revocation cannot be for a minor in possession, intermediate license violations, failure to pay child

support, fraud, violation of court-ordered probation, medical or vision reasons, habitual traffic offender status, failure to enter into or comply with a required alcohol/drug treatment program, or vehicular assault or homicide (except under certain conditions). ? You must be a Washington licensed driver or hold a valid out-of-state driver license. The restricted license is only legal within the state of Washington. ? A second application fee is not required for a new suspension based on the same incident date.

Required documentation ? Proof of financial responsibility ? the most common method is by filing a form called an SR-22. You can get one from most

automobile insurance agents. ? If you are suspended for an alcohol or drug-related offense, contact an ignition interlock company that installs Washington

certified devices. They will send us proof of installation.

If your employment requires you to drive a vehicle during working hours that is owned, leased, rented, or the temporary responsibility of your employer, it may be exempt. You must carry a signed Employer Declaration for Ignition Interlock Exemption (DR-500-025), available at dol..

If you are indigent, you may be eligible for assistance with costs of ignition interlock device installation, removal, and leasing. To apply, submit a Financial Assistance Application (DR-500-024) located at dol..

We must receive proof of the SR-22 insurance and any other required documentation within 30 days of receiving this application. If not, you must submit a new application and another $100 fee.

Keeping your restricted license Your restricted driver license will be cancelled if any of the following occurs: ? You are convicted of violating the restrictions. ? Your driving privilege is suspended or revoked while your restricted license is in effect. ? We receive evidence that your reason for driving is no longer valid. ? We receive notification that your financial responsibility (SR-22) is cancelled. ? We receive notification that your ignition interlock device is no longer functioning or has been removed.

Acknowledgment

Answer the following

I have read the above information and agree to all terms and conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

XSignature Print the completed form, sign here and date.

Date

RCW 46.20.308; 46.20.385; 46.20.391

DR-500-001 (R/10/19)VWA

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